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General Depression

Brief periods of depression affect just about everyone at some point in time.

It may consist of a variety of negative emotions including sadness, feeling “blue” or “down in the dumps”, pessimism, or a loss of interest in or pleasure from things that were once enjoyable. While most people are able to shake off these feelings and pull themselves out of a temporary depressive state, others are not. When those feelings persist or become serious enough to interfere with normal functioning, they are considered symptoms of a mental illness that is often referred to as “clinical depression”.

Anyone, regardless of age, gender, race, or socioeconomic status, can suffer from depression. It is estimated that 19 million Americans suffer from depression every year. Depression is not a weakness or a character flaw; it is a true medical illness. People who have depression are not just moody or having "the blues" for a few days. They have long periods of feeling very sad and lose interest in social and daily activities.

Depression changes the way a person feels, thinks, and behaves. If left untreated, an episode of major depression typically lasts eight or nine months, and may even last for years. About 85 percent of people who experience one bout of depression will experience future episodes. The good news is that, with proper treatment, most patients will improve in time.

Depression is one of the most common mental illnesses. At least 8 percent of adults in the United States experience serious depression at some point during their lives, and estimates range as high as 17 percent. It affects all types of people, regardless of sex, race, ethnicity, or socioeconomic standing. However, women are two to three times more likely than men to suffer from depression. Experts disagree on the reason for this difference. Hormonal differences are believed by many to be a contributing factor. Men are also less likely to seek help or acknowledge their symptoms, because many associate them with weakness.

Depression occurs in all parts of the world, although the pattern of symptoms can vary. The prevalence of depression in other countries varies widely, from 1.5 percent of people in Taiwan to 19 percent of people in Lebanon. Some researchers believe methods of gathering data on depression account for the different rates.

A number of large-scale studies indicate that depression rates have increased worldwide over the past several decades. Furthermore, younger generations are experiencing depression at an earlier age than did previous generations. Social scientists have proposed many explanations, including changes in family structure, urbanization, and reduced cultural and religious influences.

Although depression may occur as early as childhood and well into old age, it usually begins during a person's 20s or 30s. Depressive symptoms appear suddenly, or start slowly and then gradually get worse over months or even years. A person who develops severe depression may appear so confused, frightened, and unbalanced that observers speak of a "nervous breakdown."

Surveys indicate that people commonly view depression as a sign of personal weakness, but psychiatrists and psychologists view it as a real illness. In the United States, the National Institute of Mental Health has estimated that depression costs society many billions of dollars each year, mostly in lost work time.

Despite the availability of effective treatment, many cases of depression are never diagnosed or treated. Studies indicate that general physicians fail to recognize depression in their patients at least half the time. In addition, many doctors and patients view depression in elderly people as a normal part of aging, even though treatment for depression in seniors is usually very effective.

Types of Depression

There are many different types of depression listed in the DSM – the “Diagnostic and Statistical Manual of Mental Disorders” used by mental health professionals. One of the most common types of depression – as well as one of the most serious – is Major Depression. Episodes of Major Depression may occur alone, or as part of Bipolar Disorder. It may develop postpartum, or occur in addition to more chronic and mild depression known as Dysthymic Disorder.

Following is a list of different names for various types of depression. Some of these terms, such as “primary depression” and “reactive depression” for example, are used to “qualify” the type of depression and aren’t official diagnoses in and of themselves.

Atypical Depression

A type of major depressive or dysthymic episode characterized by an improvement in mood in response to positive events, along with hypersomnia (excessive sleep), significant increase in weight or appetite, chronic sensitivity to rejection, and / or a heavy feeling in the arms or legs.

Bipolar Depression

Depressive episodes that alternate with periods of mania or hypomania.

Cyclothymic Depression

Depressive episodes (that don’t meet the criteria for Major Depression) that alternate with hypomanic episodes for a period of at least 2 years.

Dysthymic Depression

Depression that is chronic (at least 2 years of persistent symptoms) and milder than Major Depression.

Endogenous Depression

Depression that occurs with no obvious precipitating event or cause.

Major Depression

Depression characterized by significant feelings of sadness, hopeless, feeling “down”, and /or a loss of pleasure or interest in most things.

Postpartum Depression

Depression that occurs in women within 4 weeks of giving birth.

Primary Depression

Depression that is not triggered by a medical condition or other psychiatric condition.

Psychotic Depression

Depression accompanied by delusions and/or hallucinations.

Reactive Depression

Depression that occurs in response to a stressful or traumatic event.

Seasonal Depression

Depression that occurs seasonally, usually during the fall and winter months when the days are shorter and there is less sunshine.

Secondary Depression

Depression that occurs due to a medical illness or other psychiatric illness.

Unipolar Depression

Major Depression in which there is no history of manic or hypomanic episodes.

Symptoms

Symptoms of depression may differ from person to person. They may range from mild to severe in terms of their impact. Common symptoms of depression include:

Sadness

Tearfulness

Low energy

Fatigue

Irritability

Hopelessness

Feelings of worthlessness

Excessive guilt

Increase or decrease in appetite

Sleep disturbances

Difficulties concentrating

Indecisiveness

Restlessness or agitation

Loss of interest in things that once brought pleasure

Somatic complaints

Frequent thoughts of death

Suicidal thoughts and actions

Suicide and Depression

People who suffer from depression, particularly Major Depression, may experience such extreme emotional pain and hopelessness that they consider and / or attempt suicide. For them, ending their life seems to be the only solution or means of relief available. At least 15 percent of seriously depressed people do eventually commit suicide, and many more attempt it. Depressed individuals who are seriously considering suicide often need to be hospitalized.

Psychosis and Depression

In some cases, people with depression may experience psychotic symptoms, such as delusions (false beliefs) or hallucinations (e.g. hearing voices when there’s no one else around or seeing things that aren’t actually there). Psychotic symptoms usually only appear in the most severe cases of depression, and hospitalization is often necessary. Compared to other depressed people, those with psychotic symptoms have longer hospital stays, and after leaving, they are more likely to be moody and unhappy. They are also more likely to commit suicide. See Psychosis.

Factors that Influence Symptoms

Age - Symptoms of depression often vary by age. Children with depression often complain of stomachaches and headaches. They are often irritable, may "mope around," withdraw socially, and have changes in their eating habits. They may feel unenthusiastic about school and other activities. In adolescents, common symptoms include sad mood, sleep disturbances, and lack of motivation and energy. Elderly people with depression usually complain of physical rather than emotional problems, which can lead doctors to misdiagnose their illness.

Culture - Symptoms of depression can also vary by culture. In some cultures, depressed people may not experience sadness or guilt but may have physical complaints. In Mediterranean cultures, for example, depressed people may complain of headaches or nerves. In Asian cultures they may complain of weakness, fatigue or imbalance.

Causes and Contributing Factors

No one really knows for sure why some people are very resilient to depression despite their circumstances, while others are much more vulnerable. In many cases, the cause if often due to a variety of factors that increase one’s risk. These include:

Life stressors

In some cases, depression seems to come out of the blue, even when things are going well. However, in many cases there is an obvious cause. Life stressors such as marital conflict, serious financial problems, or a significant loss (e.g. the death of a loved one or a break-up) may trigger depression. Traumatic events or a history of chronic trauma, such as childhood abuse or domestic violence, increases the risk of developing depression. Many people don’t become depressed in response stressful events or trauma, but those who do may have a biological and / or psychological vulnerability to depression.

Genetics

Depression tends to run in families. By studying twins, researchers have found evidence of a strong genetic influence in depression. Genetically identical twins raised in the same environment are three times more likely to have depression in common than fraternal twins, who have only about half of their genes in common. In addition, identical twins are five times more likely to have bipolar disorder in common. These findings suggest that vulnerability to depression and disorder can be inherited. Adoption studies have provided more evidence of a genetic role in depression. These studies show that children of depressed people are vulnerable to depression even when raised by adoptive parents.

Brain Chemistry and Hormonal Influences

Genes may influence depression by causing abnormal activity in the brain. Studies have shown that certain brain chemicals called neurotransmitters play an important role in regulating mood and emotions. Neurotransmitters involved in depression include norepinephrine, dopamine, and serotonin.

An imbalance of hormones may also play a role in depression. Many depressed people have higher than normal levels of hydrocortisone (cortisol), a hormone secreted by the adrenal gland in response to stress. In addition, an underactive or overactive thyroid gland can lead to depression.

Medical Issues as Causes of Depression

A variety of medical conditions can cause depression. These include dietary deficiencies in vitamin B6, vitamin B12, and folic acid; degenerative neurological disorders, such as Alzheimer's disease and Huntington's disease; strokes in the frontal part of the brain; and certain viral infections, such as hepatitis and mononucleosis. Certain medications, such as steroids, may also cause depression.

Anger and Response to Loss

Psychological theories of depression focus on the way people think and behave. In a 1917 essay, Austrian psychoanalyst Sigmund Freud explained depression as a response to loss - either real loss, such as the death of a spouse, or symbolic loss, such as the failure to achieve an important goal. Freud also believed that depression was essentially the result of “anger turned inward”.

Negative or Irrational Thought Processes

Irrational thought processes often play a significant role in depression. American psychiatrist Aaron Beck proposed that depressed people tend to view themselves, their environment, and their future in a negative light because of errors in their thinking. These errors include focusing on the negative aspects of any situation, misinterpreting facts in negative ways, jumping to conclusions, catastrophizing things (i.e. “making mountains out of mole hills”), and feeling responsible for every bad thing that happens to them, even when it was beyond their control.

Most people learn these self-defeating ways of looking at the world during early childhood. These “cognitive errors” make situations seem much worse than they really are and increase the risk of depression, especially in stressful situations.

Personality Traits and Depression

People with certain personality traits tend to be more vulnerable to depression. These traits include gloominess, pessimism, introversion, self-criticism, excessive skepticism and criticism of others, deep feelings of inadequacy, sensitivity to rejection, brooding, and frequent or excessive worrying. In addition, people who regularly behave in dependent, hostile, or impulsive ways tend to have a greater risk for depression.

Learned Helplessness

American psychologist Martin Seligman proposed that depression stems from "learned helplessness," an acquired belief that one cannot control the outcome of events no matter what they do. In this view, prolonged exposure to uncontrollable and inescapable events leads to apathy, pessimism, and loss of motivation. People who feel they have some control over their lives and their future tend to be less prone to depression.

Loss of Hope

Many experts believe that depression results not only from a sense of helplessness, but also from a loss of hope. The hopelessness theory attributes depression to a pattern of negative thinking in which people blame themselves for negative life events, view the causes of those events as permanent, and over-generalize specific weaknesses as applying to many areas of their life. Loss of hope is believed to play a significant role in suicidal thoughts and behaviors.

Treatment for Depression

In most cases, depression can be treated successfully. Symptoms may not completely disappear for some people, but they can usually be significantly reduced with proper treatment. The two most common types of treatment are psychotherapy and medication. A combination of both may be necessary at times.

Most cases of depression can be treated on an outpatient basis. However, hospitalization may be necessary if:

Symptoms are severe

Functioning is significantly impaired

There is a high risk of suicide

Psychotic symptoms are present

Psychotherapy

Most experts agree that psychotherapy, or psychotherapy combined with medication, is more effective in the long-term treatment of depression than medication alone. This is likely due to several reasons. For example, psychotherapy can help people gain valuable insight into why they are depressed and make lasting changes in their thinking and behaviors as a result. Therapy can also help individuals with depression learn healthy coping skills, develop better interpersonal skills, feel more empowered, and change the way they look at themselves and life in general.

Studies have shown that short-term psychotherapy can relieve mild to moderate depression as effectively as antidepressant drugs. Unlike medication, psychotherapy produces no physiological side effects. However, psychotherapy usually takes longer to produce benefits. Therapy can be quite expensive and isn’t always covered by health insurance. Unfortunately, this can be an obstacle to many people.

Cognitive Behavioral Therapy

While there are many different types of psychotherapy, research has shown that Cognitive Behavioral Therapy is one of the most effective types of therapy for the treatment of depression. Cognitive-behavioral therapy focuses on the negative and irrational thoughts and beliefs people have about themselves, their circumstances, their interactions with others, and their future. Cognitive therapists help them identify and eliminate these negative patterns and beliefs, and replace them with new, healthy, more positive and empowering thoughts and beliefs.

Interpersonal Therapy

In interpersonal therapy, the therapist helps a person resolve problems in relationships with others that may have caused the depression. The subsequent improvement in social relationships and support helps alleviate the depression.

Psychodynamic Therapy

Psychodynamic therapy views depression as the result of internal, unconscious conflicts. Psychodynamic therapists focus on a person's past experiences and the resolution of childhood conflicts. Psychoanalysis is an example of this type of therapy. While the insight derived from psychodynamic therapy can be beneficial, critics of long-term psychodynamic therapy argue that its effectiveness is scientifically unproven.

Medication

Up to 70 percent of people with depression respond to antidepressant drugs. These medications appear to work by balancing the levels of serotonin, norepinephrine, and other neurotransmitters in the brain. The positive effects of medication are usually not felt for at least 2 to 4 weeks.

Doctors cannot predict which type of antidepressant drug will work best for any particular person, so there is often a lot of trial and error involved before an effective and tolerable medication is found. Antidepressant drugs are not addictive, but they may produce unwanted side effects. To avoid relapse, people usually must continue taking the medication for several months after their symptoms improve.

Most antidepressant drugs fall into one of four categories:

Selective serotonin re-uptake inhibitors (SSRIs)

Serotonin norepinephrine reuptake inhibitors (SNRIs)

Tricyclics

Monoamine oxidase inhibitors (MAO inhibitors)

SSRIs

SSRIs are the most frequently prescribed antidepressants. This is largely because they have the fewest side effects. They may also help alleviate symptoms of anxiety, which often accompany depression. As the name suggests, SSRIs are designed to primarily balance serotonin levels in the brain. Popular SSRIs include fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil).

Potential side effects of SSRIs include insomnia, drowsiness, headaches, anxiety, and sexual dysfunction. Some patients, families of patients, and doctors have alleged that SSRIs cause violent or suicidal behavior in a small number of cases, particularly when prescribed to children and adolescents. The U.S. Food and Drug Administration has failed to substantiate this claim although there is some research that appears to support it.

SNRIs

SNRIs primarily target serotonin as well as another key neurotransmitter, norepinephrine. Doctors will often prescribe an SNRI antidepressant if SSRIs have been ineffective. FDA-approved SNRIs include venlafaxine (Effexor and Effexor XR), duloxetine (Cymbalta), and desvenlafaxine (Pristiq). Side effects may include drowsiness, dizziness, dry mouth, sexual dysfunction, insomnia, and nausea.

MAO inhibitors include isocarboxazid (Marplan), phenelzine (Nardil), and tranylcypromine (Parnate). People who take MAO inhibitors must follow a restrictive diet due to potentially dangerous interactions. They must avoid foods that contain tyramine - a substance found in wine, beer, some cheeses, and many fermented food - to avoid a dangerous rise in blood pressure. In addition, MAO inhibitors have many of the same side effects as tricyclics.

Atypical Antidepressants

Other antidepressants often used to treat depression, that don’t fit into the above categories, include bupropion (Wellbutrin, Aplenzin), trazodone (Desyrel, Oleptro), and mirtazapine (Remeron). (SNRIs are sometimes included in the “atypical” category.)

Addiction medications

In some cases, an additional medication may be prescribed to help “boost” the primary antidepressant or to treat symptoms such as psychosis or mood swings.

Mood stabilizers, such as lithium carbonate or valproic acid (Depakote), are typically prescribed for individuals with bipolar disorder (see Lithium). They are usually taken during periods of relatively normal mood to delay or even prevent subsequent mood swings.

Antipsychotic medications, such as Seroquel and Abilify, are sometimes used as adjunct medications as well. The FDA has approved Symbyax, which combines and SSRI (fluoxetine) and an antipsychotic (olanzapine) for cases of treatment-resistant depression.

ECT

Electro convulsive therapy (ECT) is sometimes used to treat severe depression in people who fail to respond to medication and psychotherapy. In ECT, a low-voltage electrical current is passed through the brain for one to two seconds to produce a controlled seizure. Patients usually receive six to ten ECT treatments over several weeks. ECT remains controversial because it can cause disorientation and memory loss. Nevertheless, research has found it highly effective in alleviating severe depression. ECT is also referred to as “electroshock therapy”.

Lifestyle Changes

For milder cases of depression, regular aerobic exercise may improve mood as effectively as psychotherapy or medication. In addition, some research indicates that dietary modifications can influence one's mood by changing the level of serotonin in the brain. Reducing and managing stress is also very beneficial for anyone struggling with or vulnerable to depression.

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